PENIEL
Application for Admission
Page 1
PENIEL
Drug/Alcohol Residential Treatment Center
P.O. Box 250
Johnstown, Pennsylvania 15907
814-536-2111 (Fax) 814-539-2871
Application for Treatment Admission
______
Today’s date Staff receiving this information
PERSONAL INFORMATION
______
Last nameFirst name Middle name
______
Street addressApartment number
______
City StateZip code
______
Home phoneCell PhoneE-Mail
______XXX – _XX - ______
Date of birth Current ageSocial security number
Can you provide copy of birth certificate? Yes No ______
Please explain if not available
Are you a United States Citizen? Yes No If not, date entered the U. S.: ______
Alien registration number______
What is the reason you chose Peniel for treatment at this time?
EMERGENCY CONTACT INFORMATION:
Name ______Relationship ______
______
Street address City State Zip code
______
Home phoneCell phone
FAMILY RELATIONSHIPS: Single Married Separated Divorced Widowed
Full name of spouse______
Do you have children? Yes No If yes, how many?______
ACADEMIC HISTORY
What is the highest grade of school completed?______
How would you rate your reading/comprehension skills Good Fair Poor Learning Disability
MILITARY HISTORY
Have you ever been in the military? Yes No If yes, which branch?______
Dates of service From:______To:______
What type of discharge did you receive?
Honorable Dishonorable Other than Honorable
Medical – Other than Honorable Medical – Dishonorable General
Please provide details (if not Honorable)______
______
DRUG/ALCOHOL HISTORY
Please list the chemicals including alcohol that you have used in the past or are currently using:
Name of drug / Frequency / Age began / Last UseHave you ever overdosed? Yes No If yes, was it accidental or intention? Please explain:______
______
Please list name of previous drug/ alcohol Treatment/Detoxification Centers:
Date of admission / Name oftreatment center / Address
(City/ State) / Length of program / Did you successfully complete / If you did not complete, what was the reason? / Release
Obtained?
(Yes/ No)
LEGAL HISTORY
Have you ever been arrested? Yes No If yes, please indicate the number of times that you have been charged for the following crimes.
PENIEL
Application for Admission
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Shoplifting _____
Robbery_____
Prostitution_____
Parole/Probation Violation__
Assault _____
Disorderly Conduct_____
Drug charges_____
Arson_____
Public Intoxication_____
Forgery_____
Rape_____
DWI/DUI_____
Weapons Offense_____
Sexual Assault_____
Burglary, larceny, B&E_____
Homicide, manslaughter____
Theft by deception_____
Terroristic Threats_____
Minor in possession_____
Underage Drinking_____
Resisting arrest_____
Receiving Stolen Property___
Criminal Mischief_____
PENIEL
Application for Admission
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Other______
Do you have any pending charges? Yes No If yes, please complete the following:
Date arrested/ charged / State arrested in / Name of Judge / List of present charges / Court dateDo you have an attorney? Yes No If yes, please provide the following:
Name______Phone number______
Address______
Have you been court ordered to complete treatment? Yes No If yes, please give details:
Date of sentence / What exactly was the sentence stipulation / Judge’s nameAre you presently on probation/parole? Yes No
If yes, what are the charges______
Date probation/parole began______Date probation/parole scheduled to end______
Please give name, telephone number, and address of current probation/parole officer:
Name______Phone number______
Address______
EMOTIONAL/MENTAL/PSYCHIATRIC HEALTH
Have you ever been evaluated or treated by a psychiatrist or other mental health professional? Yes No
Name of Doctor/Therapist / Location / Dates Attended / Diagnosis / Medication prescribed include dosage / Peniel has permission to request treatment records (Yes/ No)Check any of the following, which you have had. List age symptoms began.
Yes/No
/ Age / Diagnosis / Yes/No / Age / Diagnosis / Yes/No / Age / DiagnosisDepression / ADHD / PTSD
Anxiety/ Panic Disorder / Personality Disorder / OCD
Phobias / Mood Disorder / Bipolar Disorder
Schizophrenia / Eating Disorder (Bulimia)
(Anorexia) / ADD
Have you ever had thoughts of harming yourself or anyone in any way? Yes No Did you have a plan? Yes No
If yes, were you under the influence? Yes No
Please explain______
______
HEALTH AND MEDICAL HISTORY
Do you have Health Insurance? Yes No
If yes, please supply copy (front & back) of insurance cards. Attach to application.
Do you have a regular Primary Care Physician? Yes No If yes, please complete the following:
Name: ______Phone: ______Fax: ______
______
Address
Do you have a history of seizures? Yes No Date of last seizure:
Date of last physical examination______
Do you have any medical or dental concerns or physical disabilities? Yes No
Please describe all medical and dental concerns:______
______
______
If you have any dental needs, can they be taken care of after the completion of treatment? Yes No
Are you currently taking any prescribed medications? Yes No
Name of medication / Dosage / Reason for medication / Date started taking this medication / Doctor’s name“FEMALE APPLICANTS THIS SECTION ONLY”
Is there any chance that you are pregnant now? Yes No If yes, please give your due date______
Have you used any illegal substances or alcohol during this pregnancy? Yes No
If yes, please list the substance and the frequency: ______
EMPLOYMENT HISTORY
Are you currently employed? Yes No If yes, how long?______
If no, reason______
Will your employment be in jeopardy if in treatment? Yes No
Are you certified or licensed in any particular area? Yes No If yes, please provide copy.
REFERRAL/ CHURCH INFORMATION
Applicant’s church affiliation______
Referred By: ______
NameRelationship
______
Street addressCityStateZip code
Phone Number: ______Cell Phone Number: ______
CLINICIAN’S NOTES
The applicant was previously at Peniel Yes No If yes, dates attended: ______
Reason for discharge Dismissed/ Policy Violation Medical Wanted to terminate treatment Completion
General comments regarding admission: ______
______
______
______
Intake Interviewer SignatureDate application received
Revised 12/09